Mad as Hell: Negotiating-team nurses David Escobar, Barbara Williams (center) and Devon Icaza are set to walk out of Dominican if conditions don't improve.

Under the Knife

As the nursing force grows older and more restive, California's biggest health-care provider has pushed RNs here and throughout the state to the brink of striking

By Sarah Phelan

WITH HER BLONDE hair, creamy skin and wraparound shades, Devon Icaza, who is sipping a raspberry iced tea on Jahva House's patio, looks like a mature Nurse Betty on her day off. Only Icaza isn't on vacation.

She and the four other Dominican Hospital registered nurses gathered under a patio sun umbrella are members of the California Nurses Association's negotiating team at Dominican. Authorized on May 31 by their fellow RNs to call a two-day strike, Icaza says they are poised to give a 10-day notice of their intent to walk off the job, if the next round of contract negotiations, set for June 14 and 15, falls apart.

A walkout at the 375-plus-bed hospital would not take place in isolation. Dominican is one of 47 acute-care facilities operated by Catholic Healthcare West (CHW), the largest health-care provider in the state. Thirty-five-hundred card-carrying nurses would strike at 10 CHW-managed facilities from Santa Cruz to Sacramento. As a member of the largest nurse's union in the nation, Icaza represents a growing breed: the newly militant and mostly middle-aged nurse.

An RN at Dominican for 29 years, Icaza says she has always been a supporter of the union, but never an active member before now. "But now I am, because I want Dominican to succeed," says Icaza, who has devoted 19 years to Dominican's Intensive Care Unit. "As a nurse within a managed health-care system, I have very little meaningful input, unless as part of a collective bargaining unit."

Icaza is not alone in her sentiments. Tired of overwork, underpay and staffing shortages, nurses across the state are preparing to take on the biggest emergency in the hospital: managed health care.

The CNA currently boasts 37,000 members statewide--and counting. Last month, another 2,200 RNs at CHW facilities signed up, giving the union a total of 7,500 members within the largest Catholic hospital system in the western United Sates.

Traditionally reluctant to strike lest their patients be endangered, nurses in managed-care facilities are considering the two-day action after four months of negotiating for competitive pay, retirement health benefits and a pension plan. They are also pushing for safe staffing ratios, bans on mandatory overtime and reinforcement of the nurse's role as patient advocates.

Getting the administration's side of this simmering dispute at Dominican isn't easy. When hospital spokesperson Penny Jacobi finally got back to us, it was to refuse to comment for this article. Citing bad treatment at the hands of our reporters in the past, she would only say that negotiations between CNA and the hospital continue to move in a positive direction.

Barbara Williams, a psychiatric nurse who is also a union negotiator at Dominican, disagrees. As this story went to press, the hospital was offering the nurses a 22.5 percent raise over two and a half years -- a monetary offer that taken alone, Williams says, does not satisfy the nurses' bottom line .

"It's not a question of how much money they'll pay, but the way it would be dispersed," Williams says. "Plus there are vast differences on the question of retirement benefits and pensions, and patient-care issues." She adds that she finds it "ludicrous" that those who have been caregivers all their working lives are not automatically taken care of in old age or sickness.

"Nurses without health care get huge bills from the hospital where they work," Williams says. "There is no feeling that anything is owed back to them."

According to a National Institutes of Health study, one in three nurses under age 30, and two in 10 overall, plan to quit nursing within the year, citing heavier patient loads, understaffing and a decline in the quality of patient care. But Icaza and negotiating colleagues Lynn Szanto, Barbara Williams, David Escobar Jr. and Beth Martineau say abandoning Dominican is the last thing they want to do.

Szanto, an RN in Dominican's emergency room for more than a decade, sums it up: "We all have a stake in this community, and we want to give the best care possible to friends and family. But without adequate staffing, patient care is compromised. And that's a problem. Our nursing license requires that we be patient advocates."

Title 16 of the California Code of Regulations, Point 6, says that to be considered competent, a registered nurse "acts as the client's advocate ... by initiating action to improve health care or to change decisions or activities, which are against the interests and best wished of the client, and by giving the client the opportunity to make informed decisions about health care before it is provided."

According to CNA Communications Director Charles Idelson, because nurses are independently licensed to be patient advocates, they have a great deal of social commitment toward their patients--making them exploitable. Says Idelson, "Employers have coerced and cajoled nurses to work longer hours and not take breaks to cover up the disgraceful fact that managed-care hospitals are staffed inadequately."

That tactic may prove to be a gross miscalculation on managed care's part. Weary of doing more for less, nurses are contemplating strike action just six months before new nurse-to-patient staffing ratios are scheduled to go into effect. The union hopes that this strategy will put management squarely over the proverbial barrel.

Dominican Republic

NURSING, like most forms of care giving, has traditionally been labeled women's work and been paid and treated shabbily. As better-paid and more prestigious careers open to women, nursing has been unable to attract or retain younger recruits. As a result, nurses are an aging work force with the average age hovering at 46.

Committed to their community and patients, this maturing army is growing increasingly impatient with an institution that its outspoken members believe does not have their well-being at heart. Yet because of a crisis in staffing, nurses have been picking up extra hours and shifts, leaving them exhausted and ready to quit.

Last fall, Dominican's administration introduced "Save Our Shifts," a program that gives an extra $10 to $20 per hour to nurses who exceed the regular eight-hour shift. The program is still in place, resulting in what Escobar, who's worked in Dominican's medical/surgical oncology unit for 16 years, describes as "chronic burn-out."

Meanwhile, Catholic Healthcare West makes no bones about its mission.

"We believe in healing," states CHW's webpage. "This is our ministry. This is why we exist. At CHW hospitals and clinics, thousands of individuals perform extraordinary acts of healing every day. Lives are saved. Hope is rekindled. Dignity is restored."

Unless you're a registered nurse.

Williams, who has worked at Dominican for 20 years, says these days the hospital can be up to two nurses short per shift per unit.

"Over 43 RN positions--that's over one-eighth of our work force--remain unfilled. All this is very frustrating for the nurses, who want to take care of patients in a safe and adequate way."

Meanwhile, the push to privatize hospitals, which gained momentum during the early 1990s, is still in full swing. A $1.3 trillion industry, it continues to sell itself to communities with promises of decreased taxpayer costs, increased charity revenue and improved patient care.

But Beth Martineau, who has worked mostly in acute-care facilities for 18 years, says conditions have steadily worsened at Dominican since it became affiliated with CHW in 1989. "Patients have been entering and leaving the hospital sicker," Martineau claims.

A recent opinion poll showed that nurses are the health-care professionals the public trusts most. "And as nurses, we're saying we need more staff, and that patients need more and better care. But so far our concerns have been pooh-poohed," Williams says.

This drowning out of the nurse's voice is understandable CNA spokesman Idelson opines, given that profit is the motivating force behind managed care. "Investors in the industry have no history of health care as service to the community or patients rights," he says. "They see it as a business in which profits can be maximized by controlling and limiting what services are available."

The profit incentive, Idelson charges, has also led to nurses being laid off and replaced by unlicensed staff. "Drastic decreases in nurse-patient ratios have caused nurses to leave private hospitals and practice elsewhere," Idelson says.

According to Kay McVay, president of the CNA, Santa Cruz County has a very low nurse-to-population ratio, with approximately 500 nurses per 100,000 residents. Even so, Williams contends there is no shortage of nurses in the county, just a lack of them within managed care.

"A third of the nurses who reside within Santa Cruz County work elsewhere, because they can get higher wages which make for better conditions," she says. "Another 10 percent aren't working in nursing at all."

Code Red

AS THE BIGGEST hospital in the county and an acute-care facility, Dominican offers a broader range of services and is typically busier than Watsonville Hospital. Unlike Watsonville, whose emergency room frequently closes when it doesn't have enough staff or beds, Dominican's emergency room never closes.

As Szanto points out, the ER is the only source of medical help for many. "One in four Californians don't have health insurance," she says. "The ER is their primary treatment clinic."

Though Dominican nurses don't want to see their ER go "code red" (close its doors if there aren't enough beds or nurses), they question the safety and sanity of keeping it open 24/7, given the current staffing crisis. "Is it really to the patient's detriment to say, 'No,' if no one is there to take care of them?" asks Williams, who says competitive wages would go a long way to solving the staffing problem.

Though its Catholic affliation prevents it from doing abortions, Dominican offers one of the widest arrays of services in the county, while paying nurses the lowest rates in the county. While RNs at Dominican start at $22.52 and finish at $30.47, those at Watsonville Hospital begin at $27.07 and cap at $33.86. At Salinas Valley Memorial, nurses pull down $35 on average. Little wonder that more and more Santa Cruz-based nurses commute elsewhere to work.

When CHW's head office recently rolled Dominican into the West Bay Area for administrative purposes, CNA officials asked that Dominican' s nurses be paid Bay area rates.

"They said we should compare
ourselves with Sacramento," snorts Williams, who found the remark flippant and insulting to her intelligence, given that houses that fetch over $500,000 in Santa Cruz County go for $150,000 in Sacramento. Hospital spokesperson Penny Jacobi was quoted in the Sentinel June 1 as saying, "It doesn't make sense to Dominican to pay Bay Area rates when even government payers like Medicare don't reimburse Dominican at Bay Area rates."

CHW should know about reimbursement. On May 28, the Sacramento Business Journal reported that the group had agreed to pay $10.25 million to settle allegations of defrauding Medicare and other government programs. A week earlier, the same paper reported that the L.A.-based Daughters of Charity want CHW to return seven hospitals, claiming that the sisters can run them more efficiently and provide more charity care.

"This change would mark the first major defection of a group of hospitals from the chain since CHW began growing by acquiring and affiliating with more hospitals since the mid-1980s," wrote the Sacramento Business Journal.

Here in Santa Cruz, Williams claims Dominican gave its administrators a 30-percent raise during the 1999-2000 tax year. "The administrators' defense is that they exist in smaller numbers than us," Williams says. Metro Santa Cruz called Dominican's vice president and chief operating officer Roger Hite, but he had not verified these figures by press deadline.

Scare Tactics

DAVID ESCOBAR JR. had one foot out the hospital's door before it got unionized in the early 1990s. Today, he's the CNA's chief representative at Dominican.

Escobar says relationships between Dominican's administration and the union have been fraught under the leadership of Sister Julie Hyer, who has reigned as Dominican's president and chief executive officer since 1985. Though Escobar reports a lessening in hostility over the past months, Williams says Dominican resorted to what she describe as "scare tactics" on the eve of the strike vote.

On May 30, the hospital circulated what it called a "CNA strike vote" strategy update. "The Hospital may, as part of its strike plan, inform nurses that, if they do not show up for scheduled shifts at the time the strike is called, they will be replaced with traveling nurses through the duration of the strike and beyond," the "update" stated. "Striking nurses may not be allowed to return to work until a contract is finalized and ratified."

Williams believes the statement was an empty threat. "I doubt whether they can find that many traveling nurses, " she says. "But it underscores the punitive treatment nurses have typically received at CHW's hands. You've got 3,500 nurses across the state poised to go on strike. So though the hospital has the right to do this, it doesn't seem an action conducive to coming to an agreement. It's very punitive and uncaring."

MOTIVATED BY concerns for patient safety, RNs at CHW hospitals are preparing to strike against the backdrop of a bigger battlefield: safe staffing ratios. In October 1999, Governor Gray Davis signed AB 394, a CNA-sponsored bill recommending legally mandated safe staffing ratios. Currently under review by the California Department of Health Services, the ratios, based on 22 million publicly available discharge reports of California hospital patients, are scheduled to become law in January 2002.

But not without a battle. The California Healthcare Association has presented to the Department of Health Services its own set of ratios, which, Idelson claims, "are based on wishful thinking and smoke and mirrors."

In a letter dated March 2001, state Sen. Sheila Kuehl (D-Santa Monica), who sponsored the safe staffing ratios bill, writes, "Predictably, the hospital industry is working to make the regulations as lax as possible by encouraging the DHS to set ratios that will do little more than perpetuate the current unsafe conditions."

Williams agrees. "The hospital industry is fighting the CNA's recommendation tooth and nail, because it will lower their profit margins," she says. "At first, they said it was a ridiculous idea. Now, they're saying it's impossible to enact because there's a nursing shortage. Yes, there is a shortage, but management created it."

Idelson says when ratios similar to CNA's recommendations were introduced in Victoria, Australia, last year, nurses returned to the profession "in thousands."

If the hospital industry does succeed in overturning CNA's proposals, Idelson envisions a medical disaster. "The nursing shortage we are experiencing now would appear like the halcyon days of yore, as two to three times the numbers of nurses leave the profession."

Frontline Funnel

FOR NOW, Icaza, Williams, Szanto, Martineau, Escobar and all the other Dominican RNs are left working the frontline understaffed--an unsafe proposition that promises to exacerbate the the current shortage.

"You get to the point where you tell your supervisor that you're too exhausted to continue, but often there is no one is there to take over," Icaza says.

"Even those of us who would bend over backwards can't take it any more," Martineau adds, while Szanto explains that inadequate staffing causes the ER bottleneck to worsen,

"The ER is the funnel. Either patients face long waits in the ER, or nurses on other floors end up with 6-10 patients," Szanto says, adding that people with non-life-threatening conditions can expect two-to-five-hour waits, especially on weekends and holidays.

"With no extra staff and no one on call for night shifts, " she says, "it can take 15 to 30 minutes just to get pain medications. Sometimes we have elderly patients waiting for hours and people lying for 16-18 hours on 3-4-inch-thick mattresses" with no phone and no TV. The ER is not a restful place to have to spend all that time. We get drunks, accidents and people under arrest."

Three years ago,the state fined the Columbia Healthcare System for holding patients in the ER who were already destined for the intensive-care unit.

"ICUs already have mandated staffing ratios," explains Martineau, who thinks Dominican is getting close to the Columbia situation. Szanto agrees. "On a recent shift, the ER was told that the ICU was full. They didn't have enough nurses to staff the beds," she says, while Escobar tells how people come to the hospital, asking if there are enough nurses, and whether they should stay with family members.

"We encourage them to stay and advocate for their family members. It's becoming necessary," he says,

"We're not just a bunch of greedy nurses who want more money. We love our work, and we put a lot of time and energy into training our successors," says Williams, as the nurses finish their tea and prepare to depart Jahva House, one of them to work the late afternoon shift. "Our issue isn't with the patients and community, but with the hospital and the future of nursing," says Williams. "Without nurses, there is no health care."

On June 3, the state Senate voted to ban mandatory overtime. The DHS will announce its proposed safe staffing ratios at the end of July and allow 45 days for public comment. Meanwhile, Dominican's nurses, who have been without a contract since March 27, say they will go on strike, if contract negotiations, which have been going on for four months, are not resolved by June 14 and 15. In the event of a two-day strike action, the CNA negotiating team will give 10 days notice, and scheduled procedures would be canceled and services minimized. Though a picket line would be in place, union reps insist that all emergencies will be handled.